CHANGE DRIVER REQUEST

I, , request that , whose date of birth is and Driver's License state of issue is California Neveda Arizona Oregon Washington New Mexico Texas Oklahoma Colorado Montana N. Dakota S. Dakota New York Mississippi Georgia Florida Delaware Ohio Tennesse Illinois No License International License Foreign License and Driver's License number is be Select one Deleted from (Dropped from) Included on (Added to) my Automobile policy # .

To validate my identity, my date of birth is and the last four numbers of my social security number are .

Change Request Terms and Conditions

Any change to a policy can result in increased premium and/or fees charged by the Insurance company. In addition, Big Dan's Insurance Agency, Inc. charges a service fee of $20.00 for any and all changes made to a policy through our Agency. This fee is disclosed on the Broker/Customer Agreement all Customers sign prior to completing the policy processing. It is the Customer's responsibility to be aware of and submit correct documentation along with sufficient funds to cover all fees and/or premiums resulting from changes to Customer's policy. Customer agrees they are responsible for all fees and premiums and if not submitted at the time of the request, Customer agrees to the Broker and/or the Insurance company's billing them for such. All changes must be acknowledged and accepted in writing by the Insurance company. Changes requested to a policy in lapse or cancel status will not be made. In order to maintain the policy as active the Customer must pay any bill/invoice they receive from the Insurance company and/or Big Dan's Insurance Agency, Inc., regardless of whether or not the change requested is reflected on the bill/invoice. All fees are fully earned for services rendered regardless of policy status and/or acceptance of change(s). Submission of change request form(s) to Big Dan's Insurance Agency, Inc. is not a guarantee that requested changes have been performed.

I agree to the above terms